Surveillance studies in the U.S. have shown an increase in the number of hospitalizations for skin and soft tissue infections (SSTIs) by 29% from 2000 to 2004.1 Moreover, recent studies on the inpatient management of SSTIs have shown significant deviation from recommended therapy, with the majority of patients receiving excessively long treatment courses or unnecessarily broad antimicrobial coverage.2,3
With the ever-increasing threat of antibiotic resistance and rising rates of Clostridium difficile colitis, this update provides clinicians with a set of recommendations to apply antibiotic stewardship while effectively managing SSTIs.4
In June 2014, the Infectious Diseases Society of America (IDSA) published an update to its 2005 guidelines for the treatment of SSTIs.5 For purulent SSTIs (cutaneous abscesses, furuncles, carbuncles, and inflamed epidermoid cysts), incision and drainage is primary therapy. The use of systemic antimicrobial therapy is unnecessary for mild cases, even those caused by methicillin-resistant Staphylococcus aureus (MRSA). The use of empiric adjunctive antibiotics should be reserved for those with impaired host defenses or signs of systemic inflammatory response syndrome (SIRS). The recommended antibiotics in such patients have anti-MRSA activity and include trimethoprim-sulfamethoxazole or doxycycline for moderate infections and vancomycin, daptomycin, linezolid, telavancin, or ceftaroline for severe infections. Antibiotics should subsequently be adjusted based on susceptibilities of the organism cultured from purulent drainage.
Nonpurulent cellulitis without SIRS may be treated on an outpatient basis with an oral antibiotic targeted against streptococci, including penicillin VK, cephalosporins, dicloxacillin, or clindamycin. Cellulitis with SIRS may be treated with an intravenous antibiotic with methicillin-susceptible Staphylococcus aureus (MSSA) activity, including penicillin, ceftriaxone, cefazolin, or clindamycin.
The use of antibiotics with MRSA activity should be reserved for those at highest risk, such as patients with impaired immunity or signs of a deep space infection. Cultures of blood, cutaneous biopsies, or swabs are not routinely recommended; however, prompt surgical consultation is recommended for patients suspected of having a necrotizing infection or gangrene.
The recommended duration of antimicrobial therapy for uncomplicated cellulitis is five days, and therapy should only be extended in those who have not shown clinical improvement. Elevation of the affected area and the use of systemic corticosteroids in nondiabetic adults may lead to a more rapid resolution of cellulitis, although the clinician must ensure that a deeper space infection is not present prior to initiating steroids.
Preventing the recurrence of cellulitis is an integral part of routine patient care and includes the treatment of interdigital toe space fissuring, scaling, and maceration, which may act as a reservoir for streptococci. Likewise, treatment of predisposing conditions such as eczema, venous insufficiency, and lymphedema may reduce the recurrence of infection. In patients who have three to four episodes of cellulitis despite attempts to treat or control predisposing risk factors, the use of prophylactic antibiotics with erythromycin or penicillin may be considered.
For patients with an SSTI during the first episode of febrile neutropenia, hospitalization and empiric therapy with vancomycin and an antipseudomonal beta-lactam are recommended. Antibiotics should subsequently be adjusted based on the antimicrobial susceptibilities of isolated organisms.
For patients with SSTIs in the presence of persistent or recurrent febrile neutropenia, empirically adding antifungal therapy is recommended. Such patients should be aggressively evaluated with blood cultures and biopsy with tissue culture of the skin lesions. The recommended duration of therapy is seven to 14 days for most bacterial SSTIs in the immunocompromised patient.
The updated SSTI guidelines provide hospitalists with a practical algorithm for the management of SSTIs, focusing on the presence or absence of purulence, systemic signs of infection, and host immune status to guide therapy. Whereas the 2005 guidelines provided clinicians with a list of recommended antibiotics based on spectrum of activity, the updated guidelines provide a short list of empiric antibiotics based on the type and severity of infection.6
The list of recommended antibiotics with MRSA activity has been updated to include ceftaroline and telavancin. Of note, since these guidelines have been published, three new antibiotics with MRSA activity (tedizolid, oritavancin, and dalbavancin) have been approved by the FDA for the treatment of SSTIs, although their specific role in routine clinical practice is not yet determined.
The treatment algorithm for surgical site infections remains largely unchanged, which reinforces the concept that fever in the first 48 hours is unlikely to represent infection unless accompanied by purulent wound drainage with a positive culture. Likewise, the guidelines recommend risk-stratifying patients with fever and a suspected wound infection more than four days after surgery by the presence or absence of systemic infection or evidence of surrounding cellulitis.
A comprehensive guide to the management of specific pathogens or conditions, such as tularemia, cutaneous anthrax, and bite wounds, is largely unchanged, although the update now includes focused summary statements to navigate through these recommendations more easily.
The updated guidelines provide a more robust yet focused set of recommendations for the diagnosis and treatment of bacterial, fungal, and viral skin infections in immunocompromised hosts, especially those with neutropenia.
The 2014 update to the IDSA practice guidelines for SSTIs contains a chart to help clinicians diagnose and manage common skin infections more effectively. The guidelines’ algorithm stratifies the severity of illness according to whether or not the patient has SIRS or is immunocompromised. The authors recommend against the use of antibiotics for mild purulent SSTIs and reserve the use of anti-MRSA therapy mainly for patients with moderate purulent SSTIs, those with severe SSTIs, or those at high risk for MRSA. Likewise, the use of broad spectrum gram-negative coverage is not recommended in most common, uncomplicated SSTIs and should be reserved for special populations, such as those with immune compromise.
The guidelines strongly recommend a short, five-day course of therapy for uncomplicated cellulitis. Longer treatment courses (i.e., 10 days) are unnecessary and do not improve efficacy for those exhibiting clinical improvement by day five.
Drs. Yogo and Saveli work in the division of infectious disease in the department of medicine at the University of Colorado School of Medicine in Aurora.
- Edelsberg J, Taneja C, Zervos M, et al. Trends in the US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009;15(9):1516-1518.
- Jenkins TC, Sabel AL, Sacrone EE, Price CS, Mehler PS, Burman WJ. Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship. Clin Infect Dis. 2010;51(8):895-903.
- Jenkins TC, Knepper BC, Moore SJ, et al. Antibiotic prescribing practices in a multicenter cohort of patients hospitalized for acute bacterial skin and skin structure infection. Infect Control Hosp Epidemiol. 2014;35(10):1241-1250.
- U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed February 8, 2015.
- Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52. Stevens DL, Bisno AL, Chambers HF, et al.
- Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.